Research Article

Our Experience of Laparoscopic Colorectal Surgery: Short Term Outcomes


  • Eyüp Murat Yılmaz
  • Erdem Barış Cartı
  • Altay Kandemir

Received Date: 29.08.2016 Accepted Date: 19.09.2016 Turk J Colorectal Dis 2016;26(4):108-112


Currently laparoscopic colorectal surgery began to be a widely used procedure in many centers. We aimed to present early period outcomes of first group of patients who had laparoscopic colorectal surgery in our clinic.


Included were 30 patients who underwent laparoscopic colorectal surgery between September 2014 and August 2016 in Adnan Menderes University Faculty of Medicine General Surgery Clinic.


A total of 30 patients were included to this study. Low anterior resection were performed in 11 (36.7%) patients, right colectomy in 10 (33.3%) patients, anterior resection in seven (23.3%) patients, total colectomy in one (3.3%) patient, abdominal perineal resection in one (3.3%) patient. Median operation time was 149.67 (range, 100-300) minutes. The median postoperative length of stay was 6.87 (range, 3-34) days. Anastomic leakage occurred in two patients (6.7%), ureter damage in one patient (3.3%), and wound infection in five patients (16.7%).


Our laparoscopic colorectal surgery outcomes and the literature shows similarity.

Keywords: Laparoscopy, colorectal surgery, experience


Today, minimal invasive intervention in colorectal surgery has become widespread all over the world and begun to be used quite frequently in many centers.1 It is a safe procedure with numerous significant advantages over open surgery such as shorter hospital stay, postoperative earlier recovery, better cosmetic outcomes, lower need for analgesics, and earlier normalization of gastrointestinal system functions.2 Laparoscopy was first used in 1950s as a diagnostic method and then in early 1990s, it has begun to be used in colon surgery.3 Although it is currently being widely used, laparoscopic colon resection from the right colon to the rectum is not superior to the robotic surgery in terms of surgical margin, lymph node dissection and surgery duration, but is considered less expensive than robotic surgery in terms of cost. However, there are authors defending that robotic surgery is more comfortable and advantageous than laparoscopic surgery for rectum because of narrow pelvis.4 Laparoscopic surgery has higher cost as compared to the open surgery, but significant advantages have been reported such as shorter hospital stay, lower postoperative pain and shorter recovery period leading to better wound healing and early start of adjuvant therapy in oncological patients.1,5

Currently, laparoscopic method has not been regarded as the gold standard in colorectal surgery yet. Nevertheless, it has been suggested as an alternative to the open surgery in numerous researches although it has been described by some surgeons as “hand-help” surgery because of the incision made to remove the specimen.6 In the present paper, we planned to report the first cases that underwent laparoscopic surgery in our clinic.

Materials and Methods

Cases that underwent laparoscopic colorectal surgery between September 2014 and August 2016 in the Adnan Menderes University Faculty of Medicine, Department of General Surgery were included in the study. Medical records were retrospectively reviewed. Demographic characteristics and diagnoses of the patients, localization, diameter and stage of the tumor, type and duration of surgery, number of the lymph nodes removed, duration of hospital stay, time to start on liquid diet, time to start on regular diet, and the complications were recorded. The cases, in which the procedure was started as laparoscopic surgery but then switched to the open surgery, were excluded. All patients were informed about the surgical procedure and the potential complications and their written consents were obtained. All patients received liquid diet one day prior to the surgery and underwent appropriate intestinal cleaning together with prophylactic antibiotic and prophylaxis for deep venous thrombosis. All procedures were performed by the same surgical team. Pneumoperitoneum was established using carbon dioxide at an insufflation pressure of 12-14 mmHg. The number of trocars and the insertion sites varied depending on the procedure (Figure 1, 2). For the right colectomy, approximately 4-5 cm incisions were made both under and above the umbilicus; the wound protector was placed into these sites and the specimen was removed out of the abdomen through these sites and anastomosis was performed by stapler out of the abdomen. Stapler patency was closed with stapler again and anastomosis was completed. For the left colon and rectum surgeries, 4-5 cm phannelstein incision was made and the specimen was removed through this incision site. Subsequently, anvil was placed into the proximal loop and anastomosis was performed inside. In a single case of abdominoperineal resection (APR), the specimen was removed through the anal canal. Total colectomy was performed in a case with familial adenomatous polyposis coli and the specimen was removed through the phannelstein incision. Protective loop ileostomy was performed in the cases with tumor located in the lower rectum than 8 cm and with the risk of anastomosis.

Liquid diet was given to the patients on the postoperative day 1 or 2 depending on the patient’s general status and safety of anastomosis. On the following days, the diet was gradually increased based on gas and stool passage; the patients were discharged from the hospital with healing; and early complications were recorded.

Statistical Analysis

SPSS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) statistical package program was used for data analysis. Variables were presented as mean ± standard deviation, median (minimum-maximum), percentage and frequency.


A total of 30 patients were enrolled in the study. Of the patients, 18 (60%) were male, 12 (40%) were female, and the mean age was 64.5 (45-81) years. Eleven cases (36.7%) underwent low anterior resection (LAR), 10 cases (33.3%) underwent right colectomy, seven cases (23.3%) underwent anterior resection, one case (3.3%) underwent total colectomy, and another case (3.3%) underwent APR. The entire study group consisted of malignancy patients (100%). The mean tumor diameter was 4.43 cm (2-8.70). According to the TNM staging, three (10%) were stage 1, 13 (43.3%) were stage 2, 13 (43.3%) were stage 3, and one (3.3%) was stage 4 patient. The mean number of lymph nodes removed at dissection was 16.53 (8-34). With regard to the surgical methods, the mean number of lymph nodes removed at dissection was 16.1 (8-24) in LAR, 20.8 (14-34) in right colectomy, 17.4 (14-29) in AR, 13 in total colectomy, and 12 in APR. The mean surgery duration was 149.67 (100-300) minutes. The mean duration of hospital stay was 6.87 (3-34) days. The mean time to start on liquid diet was 1.3 (1-3) days and the mean time to start on regular diet was 2.8 (2-8) days. While a total of two patients (6.7%) developed anastomosis leakage, one patient (3.3%) had full-thickness cut through the ureteral wall, and 5 patients (16.7%) developed wound-site infection. Mortality occurred in none of the cases. Stoma was opened for anastomosis leakage. Full-thickness cut through the ureteral wall was repaired by placing percutaneous nephrostomy catheter and then performing ureteroureterostomy anastomosis over the double-j catheter by a team of urologists approximately after two months. Wound site infection was brought under control with oral antibiotic therapy (Table 1, 2).


Although advanced laparoscopic surgery is currently being used safely for various procedures in many centers, it has not considered as the gold standard in colorectal surgery yet.6,7 However, it is advantageous over open surgery in many aspects including cosmetic appearance, early recovery, less frequent postoperative pain, lower rate of wound site infection, and lower rate of incisional hernia.8,9 Adequate number of lymph nodes removed at dissection and the tumor-free biopsy margin and radial margin are the most critical criteria accepted currently for survival in malignancy cases.10 Comparing these two procedures in terms of oncological principles, none of them is superior to the other.5,10 Gupta and Watson11 compared laparoscopic colorectal surgery with open colorectal surgery and demonstrated that laparoscopic colorectal surgery less frequently causes trauma-induced immune system injury and immune dysfunction. Many studies in the literature report the incidence of complications to be 1.5-36% in laparoscopic colorectal surgery.12,13 The present study as well is in line with the literature. Major complications such as anastomosis leakage and full-thickness cut through the ureteral wall were encountered in 10% of study population. Full-thickness cut through the ureteral wall occurred in the second case of our learning curve, and no iatrogenic ureteral injury occurred thereafter. It is conspicuous that anastomosis leakage was encountered in two cases that underwent right colectomy procedure but not in the cases that underwent left colon and rectum surgeries. We think that protective ileostomy in rectum surgeries prevents leakage. In the right colectomy procedure, proximal ileal loop and distal transverse colon were removed out of the abdomen through the mini laparotomy incision and the anastomosis was completed using two linear staplers without reinforcing Lambert sutures. Because of high anastomosis leakage rate as 20% in the right hemicolectomy cases, we decided to perform manual anastomosis (Connell suturing by 3/0 vicryl in the first line and then Lambert suturing by 3/0 vicryl in the second line), in which we have gained experience during open surgeries, or to use reinforcing sutures by 3/0 vicryl in the future ileotransversostomy anastomoses where we use two linear staplers.

We think that mean surgery duration is shortened with increasing experience on laparoscopy. In the literature, there are studies reporting that nearly 20-30 procedures are required for a surgeon to be considered experienced.3,14 Gilmore et al.15 reported the mean surgery duration as 156 minutes, which was 149.67 minutes in the present study. We observed that the surgery duration, which was longer than 200 minutes in the first 10 cases, have decreased gradually. For this reason, we think that advanced laparoscopy performed carefully and persistently in every surgical procedure enhances the experience.

In the present study, the mean duration of hospital stay was 6.87 days. Attaallah et al.7 found the mean duration of hospital stay as 5 days for 33 patients. The higher mean duration of hospital stay in the present study was attributed to the presence of three patients with major complications. Nevertheless, based on the studies in the literature that compared the open surgery with laparoscopic surgery, duration of hospital stay is shorter in laparoscopic surgery.


Although currently the laparoscopic colorectal surgery is not the gold standard, it gives satisfactory outcomes as compared to open surgery in many aspects such as oncological principals, cosmetic outcomes, early recovery, and patient satisfaction. Considering the short-term outcomes of the present study, the results are consistent with the literature.


Ethics Committee Approval: Retrospective study, Informed Consent: Consent form was filled out by all participants.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Eyüp Murat Yılmaz, Concept: Eyüp Murat Yılmaz, Erdem Barış Cartı, Altay Kandemir, Design: Eyüp Murat Yılmaz, Erdem Barış Cartı, Altay Kandemir, Data Collection or Processing: Eyüp Murat Yılmaz, Erdem Barış Cartı, Altay Kandemir, Analysis or Interpretation: Eyüp Murat Yılmaz, Literature Search: Eyüp Murat Yılmaz, Writing: Eyüp Murat Yılmaz.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

  1. Miskovic D, Ni M, Wyles SM, Tekkis P, Hanna GB. Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases. Dis Colon Rectum 2012;55:1300-1310.
  2. Shanker BA, Soliman M, Williamson P, Ferrara A. Laparoscopic Colorectal Training Gap in Colorectal and Surgical Residents. JSLS 2016;20.
  3. Kalfaoğlu M, Hansel H, Cevheroğlu C, Gürkut Ö, Ciner F, Beroval Ö, ve ark. KKTC’de Laparoskopik Kolorektal Cerrahi Deneyimimiz. Kolon Rektum Hast Derg 2013;23:157-161.
  4. Wilder FG, Burnett A, Oliver J, Demyen MF, Chokshi RJ. A Review of the Long-Term Oncologic Outcomes of Robotic Surgery Versus Laparoscopic Surgery for Colorectal Cancer. Indian J Surg 2016;78:214-219.
  5. Melkonian E, Heine C, Contreras D, Rodriguez M, Opazo P, Silva A, et al. Reversal of the Hartmann’s procedure: A comparative study of laparoscopic versus open surgery. J Minim Access Surg 2016;27.
  6. Ivatury SJ, Bostock Rosenzweig IC, Holubar SD. Short-term Outcomes After Open and Laparoscopic Colostomy Creation. Dis Colon Rectum 2016;59:543-550.
  7. Attaallah W, Babayev H, Yardımcı S, Cingi A, Uğurlu MÜ, Günal Ö. Laparoscopic resection for colorectal diseases: short-term outcomes of a single center. Ulus Cerrahi Derg 2016;32:199-202.
  8. Kurt A, Tekinel M, Aksoy S, Yanar H. Laparoscopic resection for the colorectal diseases: first 26 cases. CÜ Tıp Fakültesi Dergisi 2008;30:14-19.
  9. Martel G, Boushey RP. Laparoscopic colon surgery: past, present and future. Surg Clin North Am 2006;86:867-897.
  10. Buğra D. Laparoskopik Kolon Cerrahisi. Kolon ve Rektum Kanserleri. İstanbul: 2010; 253-290.
  11. Gupta A, Watson DI. Effect of laparoscopy on immune function. Br J Surg 2001;88:1296-1306.
  12. Curet MJ, Putrakul K, Pitcher DE, Jossloff RK, Zucker KA. Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long term outcome. Surg Endosc 200;14:1062-1066.
  13. Clinical Outcomes of Surgical Therapy Study G. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-2059.
  14. Stocchi L, Nelson H. Laparoscopic colectomy for colon cancer: trial update. J Surg Oncol 1998;68:255-267.
  15. Gilmore BF, Sun Z, Adam M, Kim J, Ezekian B, Ong C, Migaly J, Mantyh CR. Hand-Assisted Laparoscopic Versus Standard Laparoscopic Colectomy: Are Outcomes and Operative Time Different? J Gastrointest Surg 2016.